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Osborn, Medical-Surgical Nursing, 2eChapter 22Question 1Type: MCSAThe nurse is discussing stroke etiology with a community group. The nurse would describe which mechanism as causing the most common kind of stroke?1. Ischemia2. Hemorrhage3. Headache4. SpasmCorrect Answer: 1Rationale 1: Eighty percent of all strokes are caused by ischemia.Rationale 2: Hemorrhagic strokes are less common than another type of stroke.Rationale 3: Headache is a symptom related to stroke but is not a causative mechanism.Rationale 4: Some strokes are caused by vasospasm, but they are not the predominant type.Global Rationale: Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 22-1Question 2Type: MCSAA patient is admitted with signs of a stroke (CVA). On admission, vital signs were blood pressure 128/70, pulse 68, and respirations 20. Two hours later the patient is not awake, has a blood pressure of 170/70, pulse 52, and the left pupil is now slower than the right pupil in reacting to light. These findings suggest which condition?1. Impending brain death2. Decreasing intracranial pressure3. Stabilization of the patient’s condition
4. Increasing intracranial pressureCorrect Answer: 4Rationale 1: Brain death is diagnosed by a lack of brain waves and inability to maintain vital function.Rationale 2: Rising systolic blood pressure, falling pulse, and a pupil that has become sluggish suggest increasing another condition.Rationale 3: This is an emergency situation that requires intervention, as the patient’s condition is becoming more unstable.Rationale 4: Rising systolic blood pressure, falling pulse, and a pupil that has become sluggish suggest increasing intracranial pressure (IICP). This is an emergency situation that requires notification of the physician.Global Rationale: Cognitive Level: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 22-1Question 3Type: MCSAA hospitalized patient has become unresponsive. The left side of the body is flaccid. The attending physician believes the patient may have had a hemorrhagic stroke. What is the nurse’s priority intervention?1. Move the patient to the critical care unit.2. Assess blood pressure.3. Assess the airway and breathing.4. Observe urinary output.Correct Answer: 3Rationale 1: Moving the patient to the critical care unit is not a priority intervention.Rationale 2: Blood pressure assessment is an important intervention but not the most vital.Rationale 3: In any unconscious patient, the airway must be protected. Assessment of the current airway and breathing status is of highest priority and will continue to be.